Prado R. et al., 2026: Chronic Pancreatitis: Role of Endoscopic Procedures.

Prado R, Chatterjee A, Sierra L, Kaul R, Vikash FNU, Syed KA, Firkins S, Alkhayyat M, Simon R, Joyce D, Coppa C, Siddiki H, Stevens T, Mohiuddin S, Chahal P.
Dig Dis Sci. 2026 Apr 27. doi: 10.1007/s10620-026-09895-6

Abstract

Purpose: Chronic pancreatitis is a progressive inflammatory disorder marked by irreversible parenchymal injury, fibrosis, and multifactorial pain. Therapeutic endoscopy plays a central role in managing obstructive phenotypes and selected complications. This review synthesizes contemporary evidence on endoscopic management of pancreatic duct stones, main pancreatic duct strictures, benign biliary strictures (BBS), pancreatic duct leaks, pancreatic pseudocysts, and endoscopic ultrasound-guided celiac plexus block, addressing the role of endoscopy.

Methods: A narrative review was performed, evaluating pain relief, ductal decompression, quality of life, adverse events, and reintervention across ERCP-based therapies, extracorporeal shock wave lithotripsy, pancreatoscopy-guided electrohydraulic or laser lithotripsy, and endoscopic management of pancreatic fluid collections and ductal leaks, and endoscopic ultrasound-guided pain interventions.

Results: In painful obstructive chronic pancreatitis, targeted endotherapy can provide symptom relief; however, randomized trials generally favor surgery drainage procedures and/or pancreatic resection over endoscopy for sustained pain control, ductal decompression, and physical quality of life, with comparable safety. ERCP alone is appropriate for small pancreatic duct stones, whereas larger stones are managed with extracorporeal shock wave lithotripsy or pancreatoscopy-guided electrohydraulic or laser lithotripsy to achieve ductal clearance. Main PD strictures are managed with dilation and stenting, with single large-caliber plastic stents preferred; routine use of fully covered self-expandable metal stents is discouraged due to higher adverse events. For chronic pancreatitis-associated BBS, fully covered metal and multiple plastic stents demonstrate similar long-term efficacy, with metal stents reducing procedural burden. Symptomatic PPCs are optimally managed endoscopically based on anatomy and ductal communication. EUS-CPB provides short-term analgesia for refractory pain.

Conclusion: Endoscopic therapy is integral to multidisciplinary CP management, offering effective, anatomy-driven interventions, while surgery remains preferred for durable pain control in selected patients.

Comment Hans-Göran Tiselius

This article is an extensive review of the management of patients with chronic pancreatitis. For the interested reader several treatment methods are mentioned, but only SWL will be of interest for those urologists/surgeons who are responsible for running a SWL unit.

Apart from shock wave treatment, ERCP, stricture dilatation, stenting, treatment of pseudocysts with ductal leak and coeliac block are discussed. For difficult-to-manage ductal stones, combined SWL and ERCP have been reported as successful.

It is of note that attention must be paid to the common occurrence of co-morbidities in patients with chronic pancreatitis. Accordingly, it is mentioned that the long-term mortality in patients with high alcohol consumption increases the risk with a factor of two and that of smoking with a factor four. This information was unknown for the reviewer.

For stricture treatment, plastic stents are recommended for which the success is limited to ONE stent with a large diameter.

The bottom-line is that patients with bile duct stones should be treated with SWL with or without ERCP and only when their size is > 5 mm. Literature data showed that clearance was obtained in 64-80%.

It is of value for those who are responsible for the SWL-devices to be aware of the value of this treatment method for pancreatic duct stones. In case of residual fragments ERCP is a valuable assisting method.

The more special pathological conditions cowered in this review are left for special considerations by gastroenterologists.

Hans-Göran Tiselius